T

his study included 70 patients with acute traumatic epidural hematoma (ATEH)

in Al-Gamhouria Modern General Hospital during 2014 with an age range from

3 to 75 years and a mean of 26.4 ± 19.3 years.

They were males more than females (83.3% vs. 15.7%) with significant

statistical difference (Z= 4.73, p= 0.0001).

In this study, it was observed that the peak incidence of acute traumatic epidural

hematoma was in younger patients, in the third and second decades of life (27.1% and

25.7% respectively). However, older patients (up to 70 years) can be affected also.

These patients were single more than married patients (60.0% vs. 40.0%) and

living in Aden governorate (64.3%) more than in other governorates; Lahej, Abyan and

Shabwa (24.3%, 10.0%, 1.4% respectively).

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 Table 1. Demographic characteristics of the studied patients
Patients (n = 70)
Demographic characteristic
№ %
- Sex :
Male 59 84.3

Female 11 15.7
- Age group (years):
< 10 12 17.1
10 – 19 18 25.7
20 – 29 19 27.1
30 – 39 5 7.1
40 – 49 6 8.6
50 – 59 7 10.0
≥ 60 3 4.3
Mean age ± SD (years) 25.2 ± 17.1
- Marital status:
Single 42 60.0
Married 28 40.0
- Residence:
Aden 45 64.3
Lahej 17 24.3
Abyan 7 10.0
Shabwa 1 1.4
Percentages were calculated from the total sample size (n = 70)

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 Table 2. Distribution of the studied patients by occupation

Occupation № %

Student 23 32.86

Driver 20 28.57

Heavy worker 4 5.71

Teacher 2 2.86

Engineer 2 2.86

Military work 1 1.43

Idle 18 25.71

Total 70 100.0

In regard to the patients' occupation, higher percentage of the studied patients

with acute traumatic epidural hematoma were students (32.86%) or drivers (28.57%). A

quarter of them were idles i.e. jobless (25.71%). The remainders were working in

different jobs such as heavy workers (5.71%).

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 Table 3. Mechanism of injury in the studied patients

Mechanism of injury № %

Car accident 30 42.86

Falling down 23 32.86

Motor bicycle accident 17 24.28

Total 70 100.0

The mechanism of injury on the studied patients was mainly accidents (67.14%),

including car accidents and motor bicycle accidents (42.86% and 24.28% respectively).

The remainders were injured during falling down (32.86%).

Fig.1. Mechanisms of injury in the studied patients

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 Table 4. Clinical findings in the studied patients

Patients (n = 70)
Clinical finding
№ %
- Signs and symptoms:
Vomiting 66 94.3

Seizures 20 28.6
Otorrhea 29 41.4

Rhinorrhea 17 24.3

Headache 11 15.7
- Findings during examination:
Skull fracture 57 81.4
Anisocoria 13 18.6
Focal neurological signs 11 15.7
Arterial hypertension 2 2.9
Bradycardia 0 0.0
Percentages were calculated from the total sample size (n = 70)
Most patients were having more than one finding at the same time.

The common clinical presentation of the studied patients with acute traumatic

epidural hematoma was vomiting (94.3%) followed by Otorrhea (41.4%) and seizures

(28.6%).

The common clinical finding during examination was skull fracture (81.4%)

followed by anisocoria (18.6%) and focal neurological signs (15.7%). No patient had

bradycardia.

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 Table 5. Distribution of the studied patients according to Glasgow Coma
Scale
Level of consciousness according to
№ %
Glasgow Coma Scale (GCS)

≥ 13 44 62.86

9 – 12 16 22.86

≤8 10 14.28

Total 70 100.0

According to the Glasgow coma scale, a score of ≥13 was observed in more than

half of the studied patients with ATEH (62.86%), followed by 22.86% of them with a

score of 9-12. The remainders 14.28% were having a score of ≤ 8.

Fig.2. The Glasgow coma scale of the studied patients

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 Fig. 3. Percentages of patients performed X-ray and CT scan and those develop

coagulopathy

All the studied patients with ATEH underwent brain CT scan, while 69(98.6%)

performed skull X-ray and only 2(2.9%) were having coagulopathy.

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 Table 6. Distribution of the studied patients according to the time
interval between arrival till brain CT scanning
The time interval between
№ %
arrival till brain CT scanning

< 2 hrs 41 58.6

2 - 6 hrs 26 37.1

> 6 hrs 3 4.3

Total 70 100.0

The time interval between the arrival of patients till brain CT scanning was less

than 2 hours in 58.6% of the studied patients with acute traumatic epidural hematoma. It

was between 2 and 6 hours in about 37.1% and more than 6 hours in 4.3% of them.

Fig.4. Time interval till brain CT scanning in the studied patients

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 Table 7. Distribution of the studied patients according to the site of
hematoma and its density detected by brain CT scanning
Patients (n = 70)
Item
№ %
- Site of hematoma:

Temporal lobe 33 47.1

Parietal lobe 29 41.4

Frontal lobe 28 40.0

Occipital lobe 6 8.6

Cerebellum 2 2.9

- Hematoma density:

Hyperdense 65 92.9

Hypodense 1 1.4
Percentages were calculated from the total sample size (n = 70)
Some patients were having more than one hematoma site at the same time.

The site of hematoma as detected by CT scan in the studied patients showed

mixed hematoma sites (more than one site at the same time); it was temporal, parietal or

frontal site (47.1%, 41.4% and 40.0%) respectively.

While the density of hematoma was hyperdense in the majority of them (92.9%)

and no patient was found to have a mixed hematoma density on brain CT.

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 Table 8. Distribution of the studied patients according to intervention

Patients (n = 70)
Item
№ %
- Surgical intervention: (n = 70)
Yes 32 45.7

No 38 54.3

- Time of intervention: (n = 32)

< 6 hrs 20 62.5

≥ 6 hrs 12 37.5
Percentages were calculated from the sample size indicated for each item.

Surgery was the intervention of choice in 45.7% of the studied patients with

acute traumatic epidural hematoma and the time of intervention was <6 hours in the

majority of them (62.5% of those with intervention).

Fig. 5. Distribution of the studied patients according to intervention

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 Table 9. Distribution of the studied patients according to the pattern of
hematoma seen during operative findings

Hematoma pattern № %

Clotted hematoma 25 78.1

Partial liquefied hematoma 3 9.4

Active bleeding 4 12.5

Total 32 100.0

Intra-operatively, in most of the studied patients with acute epidural hematoma,

there was a clotted hematoma (78.1%) and an active bleeding was detected in 12.5% of

them, while partial liquefied hematoma was observed in 9.4% of them. No patient was

found to have a completely liquefied hematoma.

Fig. 6. Distribution of the studied patients according to the pattern of hematoma

seen during operative findings

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 Table 10. Hematoma volume and diameters in the studied patients with
traumatic epidural hematoma
Item Mean ± SD Min. – Max.

Hematoma volume (ml) 33.93 ± 28.4 0.4 – 139.0

Transverse diameter (cm) 2.92 ± 1.71 0.5 – 8.0

Antero-posterior diameter (cm) 4.54 ± 2.54 0.5 – 10.0

Cranio-caudal diameter (cm) 4.48 ± 3.8 0.5 – 37.0

Evaluation of hematoma intraoperatively revealed that the mean hematoma

volume was 33.93 ± 28.4 ml. The mean antero-posterior diameter (4.54 cm) and the

cranio-caudal diameter (4.48 cm) were greater than the transverse diameter (2.92 cm).

Fig. 7. The mean hematoma diameter in the studied patients

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 Table 10. Hospitalization of the studied patients

Hospitalization № %

Less than 1 week 17 24.3

1 – 2 weeks 38 54.3

More than 2 weeks 15 21.4

Total 70 100.0

The studied patients with acute traumatic epidural hematoma were hospitalized

for a variable time ranging from 1 day to 68 days with a mean of 11.6 ± 9.8 days. More

than half of them stayed for 1 to 2 weeks (54.3%). A quarter of them remained for less

than one week (24.3%) and the reminder 21.4% remained in the hospital for more than

2 weeks.

Fig. 8. Distribution of the studied patients according to hospitalization time

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 Table 11. Distribution of the studied patients according to the
Glasgow Outcome Scale
Glasgow Outcome Scale № %
Good recovery 52 74.3

Moderate disability (able to live independently) 6 8.6

Severe disability (unable to live independently) 4 5.7

Died patients 8 11.4

Total 70 100.0

According to the Glasgow Outcome Scale, higher percentage of the studied

patients with acute traumatic epidural hematoma had good recovery (74.3%). The

remainder patients either with moderate disability (8.6%) or with severe disability

(5.7%). About 11.4% of the studied patients died.

Fig. 9. Distribution of the studied patients according to the Glasgow Outcome

Scale

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 88.6%
Alive patients

11.4%
Case fatality rate

Fig.10. The case fatality rate related to acute traumatic epidural hematoma

The case fatality rate associated with acute traumatic epidural hematoma in this

study was 11.4%, i.e. from each one hundred patient with acute traumatic epidural

hematoma 11.4 patients died with or without intervention.

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Table 12. Different factors in relation to the Glasgow Outcome Scale in
the studied patients
Glasgow Outcome Scale
Factors Good recovery Disability Death p
(n= 52) (n= 10) (n= 8)
№ % № % № %
- Age of patient (years):
≤ 20 28 53.8 3 30.0 1 12.5
21- 40 17 32.7 4 40.0 3 37.5
0.026
41 - 60 7 13.5 3 30.0 2 25.0
> 60 0 0.0 0 0.0 2 25.0
- Mechanism of injury:
Car accident 21 40.4 2 20.0 7 87.5
Fall Down 20 38.5 3 30.0 0 0.0 0.021*
Motor bicycle accident 11 21.1 5 50.0 1 12.5
- Glasgow Coma Scale :
> 13 43 82.7 1 10.0 0 0.0
9 - 12 8 15.4 7 70.0 1 12.5 0.0001*
<8 1 1.9 2 20.0 7 87.5
- Surgical intervention:
< 6 hrs 14 26.9 2 20.0 3 37.5
> 6 hrs 2 3.9 6 60.0 5 62.5 0.0001*
None 36 69.2 2 20.0 0 0.0
- Hematoma volume:
< 30 ml 38 73.1 2 20.0 0 0.0
0.0001*
≥ 30 ml 14 26.9 8 80.0 8 100.0

In regard to patients age; good recovery was higher among younger patients

(≤20 years; 53.8%), while disability and death were more at the age group 21-40 years

(40.0% and 32.7%) respectively. These differences were found statistically significant

(p<0.05).

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 In the mechanism of injury, car accidents were significantly associated with

higher percentage of death (87.5%), while motor bicycle accidents were significantly

associated with higher percentage of disability (50.0%). However, from a 23 patients

with falling down 20 of them with good recovery and 3 with disability.

Glasgow coma scale of < 8 was significantly associated with lower percentage

of disability (20.0%) and higher percentage of death (87.5%). While a scale of >13 was

significantly associated with higher percentage of good recovery (82.7%).

Early surgical intervention, within the first 6 hours was significantly associated

with 26.9% of good recovery and lower percentage of disability (20.0%), while late

surgical intervention, after 6 hours was significantly associated with higher percentage

of disability and death (60.0% and 62.5% respectively).

When hematoma volume was graded with a cutoff of 30ml, it was found that all

death cases and 80.0% of disabled patients were associated with a volume of 30ml or

more. While 73.1% of good recovered patients were associated with a volume of less

than 30ml. These differences were not found statistically highly significant (p<0.01).

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